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Psychiatric disorders in adults with Learning Disabilities detection and management Dr Vesna Jordanova Consultant Psychiatrist Learning Disability A life long condition Impairment in development of brain functions that affect cognitive abilities and emotions Criteria for a learning disability: – IQ below 70 – Impairments in functioning – Onset in infancy A learning disability is not a mental health problem Prevalence Mental health problems - between 10% and 20% of people with learning disabilities But research suggests that some people may go undiagnosed Some figures appear much higher, but they tend to include people with challenging behaviour - which is not a mental health problem Confidential Inquiry into premature deaths of people with learning disabilities 22% of people with LD were under 50 when they died, compared with 9% of people without LD Women with LD die 20 years sooner, than those without LD Men with LD die on average 13 years younger Most common reasons of death delays or problems with diagnosis or treatment two-fifths of people with LD died from causes amenable to good quality healthcare Learning Disability Global impairment of intellect (IQ < 70 equal to 2.5% of population) Acquired before age 18 (developmental period) Social / Occupational impairment AKA Mental retardation (old, but still in ICD-10) AKA Intellectual disability (new) Learning Disability Prevalence > Men 2.5% predicted by IQ distribution, but actual LD probably lower Mainly Mild LD (50-70 IQ est) Moderate LD: IQ around 35-50 Severe LD: IQ < 35 (but not meaningful at this point) Learning Disability: Causes CNS Insult (e.g. Hypoxia, infection) Specific Genetics: – Trisomy 21 most common genetic cause – Fragile X most common inherited cause (triplicate repeat on X chromosome) – Many others: incl many micro deletions, trisomys, sex chromosome abnormalities – XXY, XO have, on average, slightly lower IQ, but not normally in LD range. (Possibly XYY too). Learning Disability: Mental Health Schizophrenia Probably 3% Incidence BAD 1.5%, possibly more Most mental illness believed to be increased in prevalence (up to x3) in LD Anorexia less common (but overall eating disorders more common) Schizophrenia and Learning Disabilities Higher prevalence: – Approximately 1% of general population – Approximately 3% of learning disability population On average earlier onset: – General population - 26.8 years – Learning disability population - 22.5 years Learning Disability: Mental Health Prognosis probably worse: particularly studied in schizophrenia, more insidious and malign. Some specific associations with Trisomy 21 – Depression – Dementia (of Alzheimer's type), early onset. Vicious Cycle of Social Exclusion Lower Self-Esteem Increased Levels of Isolation Reduced Opportunities Mental Health Problem Stigma Discrimination Schizophrenia and Learning Disabilities Diagnosis of Schizophrenia relies on language based criteria People with LD often unable to communicate complex experiences Delusions in people with LD – may be less complex - delusions are drawn from the person’s more limited field of experience Hallucinations in people with learning disabilities: – may express their hallucinations in broad terms without details – may not be able to explain further when asked specifics Schizophrenia and Learning Disabilities Symptoms may be atypical Other symptoms in people with mild to moderate learning disabilities: – social withdrawal – fearfulness – sleep disturbance – simple delusions and hallucinations Behaviours in people with learning disabilities that may be mistaken for schizophrenia: May invent their own words due to: – not knowing the appropriate word – autistic neologisms – “pet” words – having a limited vocabulary Schizophrenia and Learning Disabilities May still have child-like beliefs, which have been perpetuated by family or carers Fantasy worlds May be aloof May be uncommunicative Mood Disorders and Learning Disability Presentation in people with learning disabilities: Relatively easier to diagnose than schizophrenia due to the biological and behavioural changes - even in people with severe learning disabilities Prevalent in 1-6% of the LD population Anxiety and Learning Disabilities Presentation of anxiety in people with learning disabilities: Irritability Difficulties getting to sleep Physical complaints Principles of Assessment Mild learning disabilities and reasonable verbal communication skills: – assessment is similar to the general population Severe learning disabilities and limited communication skills: – rely on changes in behaviour and the observations of others Always consider possible underlying physical illness - this may contribute to changes in behaviour and functioning Assessment – Current Situation What is the person normally like? What has changed? Possible signs and symptoms Recent life events – transitions, changes in circumstances, change in staff or routine, frequency of family contact, abuse, bereavement, new service user Why are you reporting this now? LD: Assessment, Communication Keep speech simple, jargon-free, one concept at a time. Beware acquiesce: – Are you happy? – Are you sad? – Are you Ming the Merciless? Beware Yes Yes Yes suggestibility: – Are you happy or sad? – Are you sad or happy? Sad Happy LD Assessment, Communication (Almost) always communicate with PWLD first – this is the most frequent complaint of PWLD. However, don’t be shy to ask an informant for information or to help with communication Visual prompts can help at time. Things that can help in an assessment – – – – – – – ABC charts sleep charts weight charts current drug card recent skills assessments incident reports seizure monitoring chart Principles of treatment Multidisciplinary Partnership User and carer involvement Optimal inter-professional communication. The issue of valid ,informed consent. Assessment of capacity. Learning Disability: treatment Medication normally used more slowly / cautiously (sensitivity to side effects) Epilepsy more common: care with proconvulsant effect of many psychiatric drugs (and interaction with anti convulsants). Psychological therapies used, particularly CBT Behavioural management CPA Used Autistic Spectrum Disorders Qualitative abnormalities in reciprocal social interaction Communication abnormalities Restricted, stereotyped repetitive interests and activities Pervasive Onset in childhood Prevalence of ASD in the UK The UK National Surveys of Psychiatric Morbidity 2007 First population-based study of adults with autism (Brugha et al. 2009) prevalence of autism - 0.9% 88.9%- male 56.3%- unemployed 56.9%- single 8.5%- ICD-10 neurotic disorder ASD: Communication and Assessment Neurodevelopmental important history very – Imaginative play – Interaction with other children – Pointing out objects – Understanding others internal mind (theory of mind) – Generalised motor clumsiness – Restricted area of interest ASD: Communication and Assessment Try and interview in side room / quiet, non distracting area (ASD = sensitive to noise++) New environments usually very distressing to ASD, bear this in mind. A trusted support worker, family, friend, makes this easier. Avoid euphemisms, and relying on nonverbal communication Try and keep things unambiguous, “black and white”, concrete. Watch out! Misdiagnosis… Is it….? Obsessive Compulsive Disorder/Personality Or… Autistic rituals and need for sameness Auditory hallucinations Or… Unusual sensory experiences Depression Or… Lack of emotional expression Bipolar disorder Or… Changeable mood/ over-excitability Borderline Personality Disorder Or… Emotional lability in AS and poor theory of mind/social skills Autism or schizophrenia Social isolation, lack of general interests and slow response may be contributed to “negative symptoms” Communication difficulties (odd, overinclusive speech) may be mistaken as “thought disorder” Incomplete/odd answers can sound like delusions Catatonia Autistic behaviour can be alleviated by use of antipsychotics ASD in adulthood It is a lifelong disability The costs of supporting adults with ASD in the UK amount to 25 billion pounds each year (NAS 2010) Only 15% of people with ASD in the UK are employed (National Audit Office 2009) Comorbidity in autism is associated with negative long-term outcomes Contact Details Vesna Jordanova Email: [email protected]
